|
BRAF Mutation
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$143.40 |
| Max. Negotiated Rate |
$770.96 |
| Rate for Payer: Aetna Commercial |
$754.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$720.68
|
| Rate for Payer: Aetna Managed Medicare |
$175.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$657.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$306.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.16
|
| Rate for Payer: Anthem Medicaid |
$143.40
|
| Rate for Payer: Anthem Medicare Advantage |
$175.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$175.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$175.40
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$770.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$175.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$143.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$468.94
|
| Rate for Payer: Dean Health Medicaid |
$143.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$175.40
|
| Rate for Payer: Health EOS Commercial |
$745.82
|
| Rate for Payer: HFN Commercial |
$770.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$652.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$143.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$175.40
|
| Rate for Payer: Managed Health Services Medicaid |
$149.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$175.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$175.40
|
| Rate for Payer: Multiplan Commercial |
$670.40
|
| Rate for Payer: NAPHCARE Commercial |
$263.10
|
| Rate for Payer: Preferred Network Access Commercial |
$770.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$143.40
|
| Rate for Payer: Quartz Beloit One Network |
$410.62
|
| Rate for Payer: Quartz Commercial |
$544.70
|
| Rate for Payer: Quartz Medicare Advantage |
$175.40
|
| Rate for Payer: The Alliance Commercial |
$701.60
|
| Rate for Payer: United Healthcare Medicaid |
$143.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$175.40
|
| Rate for Payer: United Healthcare PPO |
$628.50
|
| Rate for Payer: WEA Trust Commercial |
$460.90
|
| Rate for Payer: Wellcare Medicare |
$175.40
|
| Rate for Payer: WMAP Medicaid |
$143.40
|
| Rate for Payer: WPS Commercial |
$620.71
|
|
|
BRAF Mutation
|
Professional
|
Both
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$368.72 |
| Max. Negotiated Rate |
$796.10 |
| Rate for Payer: Aetna Commercial |
$796.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$720.68
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$796.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$419.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.80
|
| Rate for Payer: Health EOS Commercial |
$762.58
|
| Rate for Payer: HFN Commercial |
$796.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$619.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$619.16
|
| Rate for Payer: Multiplan Commercial |
$670.40
|
| Rate for Payer: Preferred Network Access Commercial |
$796.10
|
| Rate for Payer: Quartz Beloit One Network |
$368.72
|
| Rate for Payer: Quartz Commercial |
$477.66
|
| Rate for Payer: The Alliance Commercial |
$419.00
|
| Rate for Payer: WEA Trust Commercial |
$460.90
|
| Rate for Payer: WPS Commercial |
$620.71
|
|
|
BRAF Mutation
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$410.62 |
| Max. Negotiated Rate |
$770.96 |
| Rate for Payer: Aetna Commercial |
$754.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$720.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.14
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$770.96
|
| Rate for Payer: Health EOS Commercial |
$745.82
|
| Rate for Payer: HFN Commercial |
$770.96
|
| Rate for Payer: Multiplan Commercial |
$670.40
|
| Rate for Payer: NAPHCARE Commercial |
$502.80
|
| Rate for Payer: Preferred Network Access Commercial |
$770.96
|
| Rate for Payer: Quartz Beloit One Network |
$410.62
|
| Rate for Payer: Quartz Commercial |
$502.80
|
| Rate for Payer: WEA Trust Commercial |
$460.90
|
| Rate for Payer: WPS Commercial |
$620.71
|
|
|
Brain cavity shunt w/scope 62201
|
Professional
|
Both
|
$6,406.00
|
|
|
Service Code
|
CPT 62201
|
| Hospital Charge Code |
6178531
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,093.85 |
| Max. Negotiated Rate |
$6,085.70 |
| Rate for Payer: Aetna Commercial |
$6,085.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,509.16
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cigna Commercial |
$6,085.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,093.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,843.60
|
| Rate for Payer: Health EOS Commercial |
$5,829.46
|
| Rate for Payer: HFN Commercial |
$6,085.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,797.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,797.72
|
| Rate for Payer: Multiplan Commercial |
$5,124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,085.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,818.64
|
| Rate for Payer: Quartz Commercial |
$3,651.42
|
| Rate for Payer: The Alliance Commercial |
$3,203.00
|
| Rate for Payer: United Healthcare Medicaid |
$1,093.85
|
| Rate for Payer: WEA Trust Commercial |
$3,523.30
|
| Rate for Payer: WPS Commercial |
$4,744.92
|
|
|
BRA JODEE - 2 X LG
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971181
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.87 |
| Max. Negotiated Rate |
$425.96 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$277.80
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE - 2 X LG
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971181
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$1,852.00 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Managed Medicare |
$129.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.09
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$300.95
|
| Rate for Payer: Quartz Medicare Advantage |
$277.80
|
| Rate for Payer: The Alliance Commercial |
$1,852.00
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE EXTRA LARGE
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971180
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$1,852.00 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Managed Medicare |
$129.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.09
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$300.95
|
| Rate for Payer: Quartz Medicare Advantage |
$277.80
|
| Rate for Payer: The Alliance Commercial |
$1,852.00
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE EXTRA LARGE
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971180
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.87 |
| Max. Negotiated Rate |
$425.96 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$277.80
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE LARGE
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971179
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.87 |
| Max. Negotiated Rate |
$425.96 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$277.80
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE LARGE
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971179
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$1,852.00 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Managed Medicare |
$129.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.09
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$300.95
|
| Rate for Payer: Quartz Medicare Advantage |
$277.80
|
| Rate for Payer: The Alliance Commercial |
$1,852.00
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE MEDIUM
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971178
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$1,852.00 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Managed Medicare |
$129.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.09
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$300.95
|
| Rate for Payer: Quartz Medicare Advantage |
$277.80
|
| Rate for Payer: The Alliance Commercial |
$1,852.00
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE MEDIUM
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971178
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.87 |
| Max. Negotiated Rate |
$425.96 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$277.80
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE SMALL
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971177
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$1,852.00 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Managed Medicare |
$129.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$231.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$259.09
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.25
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$300.95
|
| Rate for Payer: Quartz Medicare Advantage |
$277.80
|
| Rate for Payer: The Alliance Commercial |
$1,852.00
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA JODEE SMALL
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971177
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.87 |
| Max. Negotiated Rate |
$425.96 |
| Rate for Payer: Aetna Commercial |
$416.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.39
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$425.96
|
| Rate for Payer: Health EOS Commercial |
$412.07
|
| Rate for Payer: HFN Commercial |
$425.96
|
| Rate for Payer: Multiplan Commercial |
$370.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$425.96
|
| Rate for Payer: Quartz Beloit One Network |
$226.87
|
| Rate for Payer: Quartz Commercial |
$277.80
|
| Rate for Payer: WEA Trust Commercial |
$254.65
|
| Rate for Payer: WPS Commercial |
$342.94
|
|
|
BRA MASETECTOMY KIT MEDEBRA 4X 52-54 IN A-C (MULTI-GENDER) MEDEKIT-007W
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$2,224.00 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$155.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.14
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.00
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$361.40
|
| Rate for Payer: Quartz Medicare Advantage |
$333.60
|
| Rate for Payer: The Alliance Commercial |
$2,224.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BRA MASETECTOMY KIT MEDEBRA 4X 52-54 IN A-C (MULTI-GENDER) MEDEKIT-007W
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$511.52 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$333.60
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BRA MASTECTOMY KIT MEDEBRA 1X 40-42 IN B-D MEDEKIT-004W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$150.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.75
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$322.20
|
| Rate for Payer: The Alliance Commercial |
$2,148.00
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA 1X 40-42 IN B-D MEDEKIT-004W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA 2X 42-44 IN C-E MEDEKIT-005W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$150.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.75
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$322.20
|
| Rate for Payer: The Alliance Commercial |
$2,148.00
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA 2X 42-44 IN C-E MEDEKIT-005W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA 3X 46-48 IN E-I MEDEKIT-006W
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611559
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$2,224.00 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Aetna Managed Medicare |
$155.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.14
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$417.00
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$361.40
|
| Rate for Payer: Quartz Medicare Advantage |
$333.60
|
| Rate for Payer: The Alliance Commercial |
$2,224.00
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BRA MASTECTOMY KIT MEDEBRA 3X 46-48 IN E-I MEDEKIT-006W
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611559
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$272.44 |
| Max. Negotiated Rate |
$511.52 |
| Rate for Payer: Aetna Commercial |
$500.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.68
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$511.52
|
| Rate for Payer: Health EOS Commercial |
$494.84
|
| Rate for Payer: HFN Commercial |
$511.52
|
| Rate for Payer: Multiplan Commercial |
$444.80
|
| Rate for Payer: NAPHCARE Commercial |
$333.60
|
| Rate for Payer: Preferred Network Access Commercial |
$511.52
|
| Rate for Payer: Quartz Beloit One Network |
$272.44
|
| Rate for Payer: Quartz Commercial |
$333.60
|
| Rate for Payer: WEA Trust Commercial |
$305.80
|
| Rate for Payer: WPS Commercial |
$411.83
|
|
|
BRA MASTECTOMY KIT MEDEBRA LARGE 38-40 IN B-D MEDEKIT-003W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611556
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA LARGE 38-40 IN B-D MEDEKIT-003W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611556
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Aetna Managed Medicare |
$150.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.51
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.75
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$349.05
|
| Rate for Payer: Quartz Medicare Advantage |
$322.20
|
| Rate for Payer: The Alliance Commercial |
$2,148.00
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
|
BRA MASTECTOMY KIT MEDEBRA MED 34-36 IN B-D MEDEKIT-002W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611555
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.13 |
| Max. Negotiated Rate |
$494.04 |
| Rate for Payer: Aetna Commercial |
$483.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.61
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$494.04
|
| Rate for Payer: Health EOS Commercial |
$477.93
|
| Rate for Payer: HFN Commercial |
$494.04
|
| Rate for Payer: Multiplan Commercial |
$429.60
|
| Rate for Payer: NAPHCARE Commercial |
$322.20
|
| Rate for Payer: Preferred Network Access Commercial |
$494.04
|
| Rate for Payer: Quartz Beloit One Network |
$263.13
|
| Rate for Payer: Quartz Commercial |
$322.20
|
| Rate for Payer: WEA Trust Commercial |
$295.35
|
| Rate for Payer: WPS Commercial |
$397.76
|
|
